Healthcare Provider Details

I. General information

NPI: 1003087685
Provider Name (Legal Business Name): ADVANCED MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2008
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 OLD PEACHTREE RD NW SUITE 102
SUWANEE GA
30024-7289
US

IV. Provider business mailing address

PO BOX 1860
LANGLEY SC
29834-1860
US

V. Phone/Fax

Practice location:
  • Phone: 877-645-3506
  • Fax: 888-273-1488
Mailing address:
  • Phone: 803-593-3411
  • Fax: 678-689-1459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number9181
License Number StateSC

VIII. Authorized Official

Name: MR. VANCE TIMOTHY WALL
Title or Position: CEO
Credential: RPH
Phone: 678-985-7246